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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> f <br /> ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA- 95201 <br /> PFAMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Sery es. <�! <br /> i Job Address • City Lot Size/Acreage <br /> F � y <br /> Owner's Name �1r "if LO Z 3e <br /> rAdBress':i ' � Phone <br /> Contractor �Addresst License No. � $ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑£ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION-0— it REPAIR C1 OTHER Q Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEVAR.LINES DISPOSAL FLD. PROP, LINE <br /> a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial <br /> ❑:Open Bottom"" `~" M( 'anteca ia. o Well Excavation Dia.'`of.�Well`Casing <br /> Cl Domestic/Private ❑'Gravel Pack C3 Tracy Type of Casing Specifications ' ! <br /> !'1 Public 1_1 Other n Delta Depth of Grout Seal I Type of Grou ' <br /> I i Irrigation +_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump, w H.P. State Work Ddne _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth t x! it <br /> Depth Filler Materiav Depth <br /> TYPE OF SEPTIC WORK: NEW INSTATION f I REPAIR/ADDITION I D STRUCTION I INo septic system permitted if publi sewer is <br /> ,V/ f availabl within feet.l <br /> Installation will serve: Residence Commercial Other A 1 <br /> Number of living units: 4Number of bedroomsf <br /> Character of soil to a depth of 3 feet: r ' IfF <br /> fat table depth <br /> SEPTIC TANK. ❑ Type/Mfg t Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. Cl ' Method of Di osai r n <br /> Distance to nearest: Wel!1JC[lL�Foundation S a Property Line <br /> LEACHING LINE LI No, & Length of lines t Total length/size <br /> i <br /> FILTER BED 'C7""D1tance to nearest: Well _Foundation Property Line <br /> SEEPAGE-PITS I l Depth �. <br /> Si:e 'F y _ Number <br /> SUMPS '' t Ll Distance to neares . W II Foundation rty Line. <br /> f Pro <br /> DISPOSAL PONDS ❑ e +. e T <br /> 1 hereby certify that l haveepsred.this application dnd Cha the work will be done 5n 6ccordancA with San J <br /> rules and regulations of the San Joaquin County y, . ,, gain county ordinances, state laws, and <br /> Home owner or licensed agent's signature certifies the fo ing: "i certify that,in Ilia performance of thew for which this permit is issued, I shall not <br /> employ any person in such.litanner as to become t6biect to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I Certify-that in the pe"40iriance of the work-f6r wh`i6h tKis pt rr6t-Ii issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The applicant ust call for e+ ,regw $petions.•Complete`drawing 6n riaviarse side. + <br /> s r <br /> 9 � x <br /> Si ned X Title: t Pate: �i C <br /> r <br /> nl FOR DEPARTMENT'USE ONLY <br /> 2 - <br /> Application'Accepted by ;" I'w + <br /> Date _ Area <br /> Pit or Grautnepection by"{ t°`[.Dater Final Inspection by Date Z O <br /> 3 <br /> �1 _ L/ If <br /> Additional Comments: "i r , <br /> i <br /> Applicant Return all copies to: San Joaquin`.County Public Health Jft <br /> Services, $ivirontaental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED W �LL <br /> INFO n CASH RECEIVED BY DATE PERMiT'NO. <br /> + EH 1321 fREV,tins f7 -� OQS <br /> EH 71.20 I� I(\ <br />